Psychiatry: A specialty relegated to the basement

Jai Shah could have been any sort of doctor he wished. Even before he graduated with honours from the University of Toronto's medical school, the 30-year-old Edmonton native had earned a master's degree in international health policy from the London School of Economics, published papers and worked for the Canadian Institutes of Health Research.

Praise follows him wherever he goes. Except for last fall – when he decided to specialize in psychiatry.

“A psychiatrist?” some of his supervisors said, “But you're smart! … You're taking the easy way out … Your patients will make your life hell … Your patients will make you depressed … What a waste of talent!”

Dr. Shah knew mentally ill people battle both their disorders and the social stigma their conditions carry. But it surprised him that psychiatrists confront a certain stigma, too.

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“I'm sure the feedback has discouraged some young doctors from choosing this as their career,” said Dr. Shah, now at the Harvard Longwood Psychiatry Residency Training Program in Boston.

In fact, Susan Abbey, who heads the U of T first-year residency program in psychiatry, said the disparaging comments are “ubiquitous.”

“I don't think there's one of our incoming residents who hasn't been exposed to negative comments from family or friends or academic supervisors,” Dr. Abbey said.

Just as lawyers can face a barrage of bottom-feeder jokes, psychiatrists, both in film and real life, have long been seen as doctors of a lesser science. Even their own physician colleagues can view their patients as difficult and time-consuming. The negativity, experts say, is contributing to a national shortage of psychiatrists and shoddy care for mentally ill people.

Across the country, Canadians are unable to see a psychiatrist when they need one. A survey from the B.C.-based Fraser Institute released last month suggests the national median waiting time for psychiatric care this year is 18.6 weeks, longer than for any physical treatment.

A Canadian Psychiatric Association survey has found that even in emergency cases – where the CPA recommends a patient be admitted for acute care within 24 hours due to a “high degree of risk to self or others” – delays in some regions range from 57 hours to nearly five days.

“It's the patients who doubly suffer from the stigma,” Dr. Shah said. “First, from the social perception of their illness and then, on top of it all, from the shortage of treaters, and the gaps in care reflect the stigma within the medical profession and that contributes [to the social perception]… so it's a vicious circle.”

Studies suggest these attitudes take a toll on medicine's front lines: Mentally ill people have a tougher time finding a family doctor, are more likely to need urgent medical care and less likely to receive life-saving treatments. They're also more likely to die of conditions such as heart attacks, strokes and cancer.

At the same time, funding for mental-health research and psychiatric services has paled compared with monies doled out for physical ailments. Mental illness, meanwhile, is the No. 1 cause of disabilities in Canada and accounts for 20 per cent of all hospital admissions.

The inequities are so apparent that the Mental Health Commission of Canada has made it a top priority to fight stigma among health-care professionals, and this year the Canadian Medical Association, which represents the country's doctors, has launched a campaign to combat the stigma within its ranks.

“Doctors will be inclined to see mental illness differently than other medical illnesses … it's not like a broken bone, you don't see it clearly,” said CMA president Dr. Robert Ouellet. “We feel mental illness has not received its fair share of attention.”

The ‘master status'

Michele Misurelli believes that doctors, despite their medical training, need more education when it comes to understanding mental illness.

A 41-year-old Calgary mother who has schizophrenia, Ms. Misurelli developed Type 2 diabetes as a result of the anti-psychotic drugs she takes. Schizophrenia, however, makes the diabetes tough to manage. Sometimes she forgets to take her insulin and, a few years ago, she ended up at a hospital emergency department with dangerously high sugar levels.

The emergency doctor was furious that she had not taken care of herself. Ms. Misurelli explained that her mental illness made it hard to do so. But the doctor stormed off and called the psychiatry ward.

“She said, ‘Get this schizo out of my emergency department. If you want to admit her to your psych ward, fine. But get her the hell out of my emergency department,' ” Ms. Misurelli recalled.

Sitting on a gurney behind a curtain, Ms. Misurelli heard the comments and wept. Ms. Misurelli, who works for the Calgary chapter of the Schizophrenia Society of Alberta, was eventually transferred to the psychiatry ward for insulin treatment.

“It wasn't a psych emergency, it was a medical emergency. But I was treated with no dignity, no respect, like I could just be shoved under the carpet,” she said. “I was not important enough to take up her [the emergency doctor's] time or a bed.”

Heather Stuart, a community health professor and stigma research expert at Queen's University, said forces that shape prejudice against mentally ill people are old and powerful – and doctors are not immune.

“Doctors are people, too,” Prof. Stuart said, and, while many are sensitive to the needs of psychiatric patients, for others mental illness tends to become “the master status.”

“Everything else is interpreted through the lens of that master status,” she explained. “Your whole being no longer matters, or what other illness you have, those things fade away, you become the illness.”

Two recent studies in Canada and the United States found that mentally ill people are more likely to die of heart attacks and strokes because they are less likely to receive equal access to treatments such as bypass surgery. This month, a report from Nova Scotia shows that mentally ill people – even after taking lifestyle factors into account – also run a higher risk of dying from cancer because of the later detection of the disease.

Other events also demonstrate the difficulties for mentally ill people needing urgent medical care. In 2002, for example, a 40-year-old man with schizophrenia died of a heart attack waiting in the emergency ward of St. Joseph's Healthcare centre in Hamilton. Reports suggest that staff, aware of his psychiatric condition, assigned Alfred (Rusty) Potter a low priority.

“It was an utter tragedy … that made us review the case and ask questions of ourselves,” said David Higgins, St. Joe's chief of staff. Among the resulting changes, he said, was an emergency department renovation to reduce the chance any waiting patient would be overlooked, added training for staff and the hiring of a mental-health nurse as the head nurse in emergency.

Prof. Stuart of Queen's noted that health-care professionals, as with society generally, have made progress. But the advances have typically been “surface stuff … intellectual knowledge – people know what depression is compared to 50 years ago.”

When it comes to personal interactions, she said, perceptions haven't changed much: “On an emotional level, we're still saying, don't come too close to me.”

A ‘soft' specialty

Of Canada's 2,000 medical school graduates in 2007, only 103 – or 5.1 per cent – listed psychiatry as their first choice of specialty. The numbers, kept by the non-profit Canadian Resident Matching Service, show 29 per cent chose family medicine, 19 per cent selected surgery and 14 per cent picked internal medicine.

Dr. Shah believes psychiatry just doesn't have the prestige of other specialties: “Some people think you don't even need to go to medical school.” When he told his family he had decided to become a psychiatrist, they were puzzled. “It could be that coming from an ethnic background, Indian, that there is a certain stigma around it,” he said. “I never heard of anyone we knew having a mental illness, and no one talks about it.”

His mother, a biochemist, and his father, an engineering professor, eventually supported his choice, but at dinners family friends still said, “Oh, not a cardiologist?”

Critics of the discipline often compare psychiatry to a pseudo-science – a field of fuzzy symptoms, controversial conditions, diagnoses and drugs.

Patrick White, chair of the psychiatry department at the University of Alberta and past president of the CPA, agrees the general view has been that psychiatry is a “soft … less challenging specialty.”

The criticism comes partly from the fact that psychiatry involves the brain, the body's least understood organ, he said. As well, psychiatric tests tend not to involve levels that can be counted or measured as with blood or urine tests. But this, Dr. White said, is changing rapidly with advances in brain-imaging scans, and in neurological and genetic research.

Dr. Abbey, current CPA president and a psychiatrist at Toronto General Hospital, said today's drug- and talk-therapy treatments for depression, anxiety and even psychosis “are way more effective in managing disease than medical treatments” for physical conditions. But the health system still places a low premium on psychiatry, she said. “Procedures tend to get paid more than thinking. … That's always a differential.”

Psychiatrists earn 15 to 50 per cent less than other specialists, she estimated – a disincentive for medical students graduating with debts of $100,000 or more. In Ontario, where family doctors increasingly operate in team practices that include a number of specialists, psychiatrists earn a full third less than the general internist per hour of patient time.

Canada faces a dearth of doctors overall – from general practitioners to surgeons. But the lack of psychiatrists, Dr. Abbey said, is exacerbated by the disparity in compensation: “The financial issue feeds the stigma. … The disparity says psychiatrists and their patients are not as valuable.”

There is bricks-and-mortar evidence as well, she said. Psychiatry wards tend to be tucked in a hospital's nether regions, “places that are physically unpleasant, with the oldest furniture.”

At the new Alberta Children's Hospital, where mental-health services were originally to be housed in a separate pavilion, the psychiatry ward has instead been located in the basement. At a new hospital under construction in south Calgary, mental-health services were also to be in a dedicated wing. But this summer, the government announced the project had run over budget and the mental-health wing would be postponed.

“Mental health is the last to be funded and the first to be cut,” said Dr. White of the University of Alberta.

But he hopes change is coming, with the work of the mental-health commission, the CMA campaign, and psychiatrists growing more assertive – protesting against cuts, lobbying for more resources, fighting the stigma against their patients and themselves. At this year's annual CPA meeting, doctors wore T-shirts that read, “I'm proud to be a psychiatrist.”

Dr. Shah, who plans to return to practice in Canada, said he sees hope for the future, especially among younger doctors. “They know,” he said of his chosen field, “that there's something to it.”

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